WEBVTT 00:00:00.256 --> 00:00:02.731 Her ejection fraction is sixty-three percent. 00:00:03.115 --> 00:00:05.525 She still cannot finish the walk she used to enjoy. 00:00:05.803 --> 00:00:08.299 A reassuring number has not explained what changed. 00:00:08.619 --> 00:00:10.921 Welcome to HEART RESERVE Clinical Conversations. 00:00:11.218 --> 00:00:14.418 I’m Lisa Zahakos, a physician assistant and founder of HEART 00:00:14.461 --> 00:00:18.856 RESERVE. In this episode, we’ll follow Renee with unexplained breathlessness, 00:00:18.984 --> 00:00:22.729 Angela with a treatment decision, and Teresa after a hospitalization. 00:00:23.105 --> 00:00:25.366 These are fictional teaching cases for clinicians. 00:00:25.622 --> 00:00:28.395 You can listen straight through, or use the chapters to 00:00:28.438 --> 00:00:30.785 return to a case. I’ll ask you to consider a 00:00:30.827 --> 00:00:33.015 few decisions and then walk through the reasoning. 00:00:33.326 --> 00:00:36.974 The activity page has the objectives, references and online questions. 00:00:37.422 --> 00:00:41.190 This episode focuses on heart failure with preserved ejection fraction. 00:00:41.586 --> 00:00:45.298 The syndrome requires more than a pumping percentage: symptoms or 00:00:45.341 --> 00:00:48.452 signs must be connected to objective cardiac evidence. 00:00:48.832 --> 00:00:53.227 Ejection fraction categories, trial entry criteria and product indications are 00:00:53.269 --> 00:00:55.204 related but are not interchangeable. 00:00:55.474 --> 00:00:59.058 Under the 2022 U S guideline and historical trial terminology, 00:00:59.271 --> 00:01:02.770 heart failure with preserved ejection fraction refers to a left 00:01:02.898 --> 00:01:06.804 ventricular ejection fraction of at least 50 percent; heart failure 00:01:06.889 --> 00:01:10.218 with mildly reduced ejection fraction refers to 41 to 49 00:01:10.303 --> 00:01:15.590 percent. The 2026 European Society of Cardiology guideline instead uses 00:01:15.803 --> 00:01:19.771 reduced ejection fraction for values below 50 percent and preserved 00:01:19.857 --> 00:01:23.246 ejection fraction for values of at least 50 percent, removing 00:01:23.416 --> 00:01:25.464 the separate mildly reduced category. 00:01:25.720 --> 00:01:29.432 Identify the guideline framework. These naming changes do not alter 00:01:29.518 --> 00:01:32.370 completed trials or U S product-label boundaries. 00:01:32.662 --> 00:01:36.928 Several trials and the finerenone heart-failure indication include left ventricular 00:01:37.056 --> 00:01:39.190 ejection fraction of at least 40 percent. 00:01:39.574 --> 00:01:42.487 Always read the actual study or label boundary. 00:01:42.756 --> 00:01:45.273 The women’s-health focus is a reason to ask a fuller 00:01:45.359 --> 00:01:47.257 history and examine care gaps. 00:01:47.620 --> 00:01:49.625 It is not a claim that every woman has the 00:01:49.668 --> 00:01:52.399 same phenotype or that a medicine works better simply because 00:01:52.441 --> 00:01:53.477 the patient is a woman. 00:01:53.744 --> 00:01:58.949 Pregnancy history, blood pressure, metabolic disease, kidney health, function and 00:01:58.992 --> 00:02:01.844 access belong in one clinical story. 00:02:02.352 --> 00:02:05.339 Let’s begin with Renee. Renee used to walk the school 00:02:05.381 --> 00:02:06.789 track while her daughter practiced. 00:02:06.960 --> 00:02:09.883 Over six months she has begun stopping after one lap. 00:02:10.117 --> 00:02:13.759 The report says left ventricular ejection fraction 63 percent. 00:02:14.073 --> 00:02:15.716 She was told the result was reassuring. 00:02:15.950 --> 00:02:18.126 She wants to know why activity has become harder. 00:02:18.425 --> 00:02:23.161 Presentation. Stable exertional dyspnea; no new chest pain, syncope or 00:02:23.204 --> 00:02:27.961 breathlessness at rest. Context. body mass index 37 kilograms per 00:02:28.003 --> 00:02:31.353 square meter; hypertension; remote severe preeclampsia. 00:02:31.587 --> 00:02:36.483 Available tests. left ventricular ejection fraction 63 percent; N T 00:02:36.568 --> 00:02:39.896 pro B N P 88 picograms per milliliter; full echo 00:02:40.024 --> 00:02:42.787 parameters not yet reviewed. Clinical task. 00:02:43.117 --> 00:02:46.018 Keep the differential open and obtain the evidence needed to 00:02:46.104 --> 00:02:48.664 explain the symptom. Begin with the change in her life. 00:02:48.920 --> 00:02:51.522 Ask Renee to describe a usual day before and after 00:02:51.693 --> 00:02:54.875 the symptoms began. A comparison with her own baseline is 00:02:54.918 --> 00:02:57.521 more useful than asking only whether she can exercise. 00:02:57.862 --> 00:02:58.993 How far does she walk? 00:02:59.228 --> 00:03:02.939 Does she stop because of breathlessness, fatigue, chest discomfort, pain 00:03:03.195 --> 00:03:06.157 or fear of falling? Is the limitation reproducible? 00:03:06.413 --> 00:03:08.184 Has the pace of decline changed? 00:03:08.547 --> 00:03:11.811 Establish the timeline before interpreting any single result. 00:03:12.131 --> 00:03:15.629 Then separate a stable outpatient problem from a potentially unstable 00:03:15.757 --> 00:03:21.197 one. New breathlessness at rest, chest pressure, syncope, severe hypoxemia 00:03:21.325 --> 00:03:25.208 or rapidly progressive symptoms require urgent assessment according to the 00:03:25.250 --> 00:03:29.325 presentation. The reassuring wording on an old echocardiogram must not 00:03:29.410 --> 00:03:31.309 override a new concerning symptom. 00:03:31.586 --> 00:03:35.597 Renee’s initial presentation is stable; that permits a structured evaluation, 00:03:35.810 --> 00:03:40.698 not a dismissal. Ask about orthopnea, waking breathless, edema, weight 00:03:40.783 --> 00:03:45.455 change, palpitations, sleep-disordered breathing and exertional chest symptoms. 00:03:45.732 --> 00:03:48.518 Reconcile prescribed and nonprescribed medicines. 00:03:48.872 --> 00:03:54.461 Review blood pressure history, atrial fibrillation, kidney disease, diabetes, valve 00:03:54.504 --> 00:03:57.159 disease and previous cardiovascular testing. 00:03:57.468 --> 00:04:01.265 A description such as 'deconditioned' may eventually be reasonable, but 00:04:01.308 --> 00:04:03.954 it should not replace the assessment needed to support it. 00:04:04.252 --> 00:04:08.210 What a preserved ejection fraction can, and cannot, tell you. 00:04:08.499 --> 00:04:12.680 Ejection fraction is the proportion of end-diastolic ventricular volume ejected 00:04:12.723 --> 00:04:15.518 with a beat. It does not directly measure filling pressure, 00:04:15.795 --> 00:04:18.952 reserve during exercise or the total burden of a multisystem 00:04:18.995 --> 00:04:22.682 illness. A woman can have preserved left ventricular ejection fraction 00:04:22.896 --> 00:04:26.565 and still have a clinically important limitation in filling, vascular 00:04:26.693 --> 00:04:28.756 function or the response to exertion. 00:04:29.071 --> 00:04:32.740 Conversely, an ejection fraction of 63 percent is not evidence 00:04:32.911 --> 00:04:36.025 by itself that heart failure with preserved ejection fraction is 00:04:36.110 --> 00:04:39.812 present. Read the entire echocardiogram in clinical context. 00:04:40.144 --> 00:04:44.666 Review chamber size, left atrial volume, wall thickness, tissue Doppler 00:04:44.709 --> 00:04:49.808 measurements, estimated filling-pressure indices, right-sided findings and valve assessment. 00:04:50.042 --> 00:04:51.972 Image quality and rhythm matter. 00:04:52.281 --> 00:04:55.908 A report of 'diastolic dysfunction' does not automatically establish symptomatic 00:04:55.951 --> 00:04:59.279 heart failure; an apparently normal resting study does not necessarily 00:04:59.449 --> 00:05:03.437 explain exertional symptoms. Do not calculate a diagnostic score with 00:05:03.479 --> 00:05:06.978 missing inputs. Renee’s ejection fraction and N T pro B 00:05:07.021 --> 00:05:09.965 N P do not supply the information required for a 00:05:10.007 --> 00:05:15.453 complete H2FPEF or HFA-PEFF assessment. 00:05:15.608 --> 00:05:18.339 A score can organize uncertainty when used in the population 00:05:18.595 --> 00:05:20.429 and context for which it was designed. 00:05:20.685 --> 00:05:23.459 Its output should help decide the next step, not substitute 00:05:23.501 --> 00:05:25.346 for reasoning. Here is the decision. 00:05:25.656 --> 00:05:29.240 Which information would most help determine whether Renee’s evaluation is 00:05:29.282 --> 00:05:31.586 on the right track? Pause here if you would like 00:05:31.672 --> 00:05:32.799 a moment to think it through. 00:05:33.072 --> 00:05:35.632 The best next step in this case is: Review the 00:05:35.675 --> 00:05:40.347 symptom trajectory, examination, full echo findings and competing causes. 00:05:40.667 --> 00:05:43.909 These findings connect her functional change to a focused diagnostic 00:05:43.952 --> 00:05:47.284 plan. Use biomarkers without letting them close the case. 00:05:47.646 --> 00:05:51.589 Natriuretic peptides are useful, but obesity can lower their concentrations. 00:05:51.991 --> 00:05:55.063 An unflagged value is therefore less reassuring when the clinical 00:05:55.191 --> 00:05:58.476 question is heart failure with preserved ejection fraction in a 00:05:58.519 --> 00:06:00.772 woman with obesity and exertional symptoms. 00:06:01.106 --> 00:06:05.117 Other conditions, including atrial fibrillation and kidney dysfunction, can also 00:06:05.287 --> 00:06:10.493 alter interpretation. Use the actual value, units, assay and context 00:06:10.706 --> 00:06:12.821 rather than the laboratory flag alone. 00:06:13.354 --> 00:06:17.151 A selected 2024 research cohort illustrates this problem. 00:06:17.450 --> 00:06:22.057 Among 78 volunteers with obesity and dyspnea, 65 percent were 00:06:22.100 --> 00:06:26.623 women. Forty qualified for invasive exercise testing; 24 were found 00:06:26.709 --> 00:06:29.141 to have heart failure with preserved ejection fraction. 00:06:29.525 --> 00:06:32.469 That is 60 percent of those tested and 31 percent 00:06:32.682 --> 00:06:35.943 of the full sample. Resting N T pro B N 00:06:36.071 --> 00:06:39.954 P and echocardiographic measures did not clearly separate the groups. 00:06:40.253 --> 00:06:43.111 These findings support a diagnostic concern; they are not a 00:06:43.154 --> 00:06:46.065 population prevalence estimate for all women with obesity. 00:06:46.374 --> 00:06:49.189 For Renee, the practical response is to obtain the missing 00:06:49.360 --> 00:06:52.338 information and reconsider the competing explanations. 00:06:52.756 --> 00:06:55.359 It is not to diagnose heart failure with preserved ejection 00:06:55.572 --> 00:06:58.815 fraction from body mass index, start every heart failure medicine 00:06:58.858 --> 00:07:02.399 empirically, or reassure her solely because the laboratory result was 00:07:02.442 --> 00:07:05.068 not flagged. Make the differential explicit. 00:07:05.238 --> 00:07:08.395 heart failure with preserved ejection fraction is one explanation for 00:07:08.438 --> 00:07:10.076 breathlessness, not the only one. 00:07:10.348 --> 00:07:15.041 The first evaluation commonly includes a focused examination, ECG, appropriate 00:07:15.084 --> 00:07:17.103 laboratory testing and review of imaging. 00:07:17.373 --> 00:07:20.786 Testing should be selected to answer the clinical question: anemia, 00:07:20.914 --> 00:07:25.735 pulmonary disease, rhythm disturbance, ischemia, significant valve disease and other 00:07:25.864 --> 00:07:29.561 causes may need consideration. Obesity can coexist with each of 00:07:29.604 --> 00:07:33.273 these conditions. Some disorders can resemble heart failure with preserved 00:07:33.358 --> 00:07:37.426 ejection fraction yet require a different diagnostic and treatment pathway. 00:07:37.697 --> 00:07:42.475 Clues to infiltrative cardiomyopathy, constrictive physiology or important valve disease 00:07:42.774 --> 00:07:47.041 should prompt directed evaluation. Do not label every thickened ventricle 00:07:47.126 --> 00:07:51.282 as ordinary hypertensive remodeling. Equally, do not send every patient 00:07:51.453 --> 00:07:54.525 with dyspnea for every advanced test; use the history and 00:07:54.568 --> 00:07:57.597 first-line findings to choose what will resolve the uncertainty. 00:07:57.938 --> 00:08:00.882 Document both the leading hypothesis and the reason it remains 00:08:00.968 --> 00:08:05.385 uncertain. 'Possible heart failure with preserved ejection fraction; full echo 00:08:05.599 --> 00:08:08.372 and alternate causes under review' is more useful than a 00:08:08.415 --> 00:08:13.175 premature definitive diagnosis. That distinction also protects later treatment decisions 00:08:13.303 --> 00:08:16.204 from being based on a diagnosis that was never confirmed. 00:08:16.503 --> 00:08:19.269 When resting data leave an intermediate probability. 00:08:19.602 --> 00:08:25.042 The HFA-PEFF framework uses clinical assessment, echocardiographic and natriuretic-peptide evidence, 00:08:25.362 --> 00:08:28.605 functional testing when uncertainty remains, and a final search for 00:08:28.648 --> 00:08:33.621 the underlying cause. The H2FPEF approach estimates diagnostic likelihood from 00:08:33.706 --> 00:08:38.088 clinical and echocardiographic features. These tools answer related questions with 00:08:38.131 --> 00:08:41.544 different inputs; disagreement or an intermediate result is a reason 00:08:41.672 --> 00:08:43.970 to review the evidence, not average the scores. 00:08:44.304 --> 00:08:47.120 In a symptomatic patient whose resting findings do not resolve 00:08:47.163 --> 00:08:51.685 the question, specialist assessment may lead to exercise echocardiography or 00:08:51.728 --> 00:08:55.935 invasive exercise hemodynamics. The choice depends on the remaining uncertainty, 00:08:56.149 --> 00:08:59.498 local expertise, feasibility and the patient’s circumstances. 00:08:59.861 --> 00:09:03.274 A normal resting pressure cannot necessarily answer what happens during 00:09:03.317 --> 00:09:05.011 the activity that produces symptoms. 00:09:05.298 --> 00:09:08.199 Explain the purpose of the referral in the order: 'Persistent 00:09:08.284 --> 00:09:13.361 exertional dyspnea with obesity and hypertension, preserved ejection fraction, nondiagnostic 00:09:13.404 --> 00:09:17.402 resting assessment; please evaluate for heart failure with preserved ejection 00:09:17.573 --> 00:09:21.968 fraction and mimics.' Include the actual tests, symptom trajectory and 00:09:22.011 --> 00:09:25.666 question. This gives the receiving clinician a starting point and 00:09:25.709 --> 00:09:28.226 makes it easier to recognize whether the referral has answered 00:09:28.354 --> 00:09:32.206 the question. Bring the history forward without overinterpreting it. 00:09:32.430 --> 00:09:35.630 Renee remembers severe preeclampsia but has never been asked about 00:09:35.673 --> 00:09:37.145 it in a general medical visit. 00:09:37.507 --> 00:09:40.366 Record the condition and timing as part of her cardiovascular 00:09:40.494 --> 00:09:44.020 history. It may strengthen the prevention conversation, but it cannot 00:09:44.276 --> 00:09:46.342 establish the cause of her current dyspnea. 00:09:46.616 --> 00:09:50.157 Pregnancy complications are not interchangeable with a past diagnosis of 00:09:50.243 --> 00:09:54.057 peripartum cardiomyopathy, and neither should be inferred without evidence. 00:09:54.458 --> 00:09:57.401 Ask what she understood from the earlier test: 'When you 00:09:57.444 --> 00:09:59.919 heard that the pumping percentage was normal, did you think 00:09:59.962 --> 00:10:02.385 that meant there could not be a heart problem?' Then 00:10:02.513 --> 00:10:07.036 correct the misunderstanding without creating unnecessary certainty: 'The pumping percentage 00:10:07.121 --> 00:10:09.852 is preserved. We still need to understand why activity has 00:10:09.895 --> 00:10:13.972 become harder. We are checking heart and nonheart causes.' Close 00:10:14.100 --> 00:10:17.428 with a concrete plan: the next test or consultation, who 00:10:17.471 --> 00:10:20.201 tracks it, how she receives the result and which new 00:10:20.244 --> 00:10:23.528 symptoms change the urgency. If transportation or cost makes the 00:10:23.572 --> 00:10:26.900 planned test unrealistic, address that before ending the visit. 00:10:27.284 --> 00:10:29.865 The outcome of this encounter is an explained next step, 00:10:30.057 --> 00:10:32.148 not simply a referral entered in the chart. 00:10:32.532 --> 00:10:36.174 Here is the decision. After reviewing the resting data, uncertainty 00:10:36.346 --> 00:10:39.354 remains. Which referral best communicates the clinical need? 00:10:39.460 --> 00:10:41.166 Pause here if you would like a moment to think 00:10:41.210 --> 00:10:43.969 it through. The best next step in this case is: 00:10:44.225 --> 00:10:48.961 Describe persistent exertional symptoms, available findings, alternatives and the question 00:10:49.132 --> 00:10:53.014 of exercise evaluation. A focused referral makes the uncertainty and 00:10:53.057 --> 00:10:57.675 desired next decision clear. The takeaway: Preserved ejection fraction and 00:10:57.718 --> 00:11:00.747 a low natriuretic peptide do not end the evaluation of 00:11:00.791 --> 00:11:05.782 persistent exertional symptoms. Confirm the syndrome, examine alternatives and track 00:11:05.868 --> 00:11:09.574 the next diagnostic step. Before we move on, let’s apply 00:11:09.616 --> 00:11:10.896 that reasoning in more detail. 00:11:11.195 --> 00:11:14.310 Test the reassurance: a worked diagnostic reveal. 00:11:14.523 --> 00:11:17.399 Return to Renee after the complete resting evaluation. 00:11:17.672 --> 00:11:20.659 There is no major valve lesion, no clear anemia and 00:11:20.702 --> 00:11:24.371 no sustained tachyarrhythmia. A complete H F A peff assessment 00:11:24.414 --> 00:11:27.870 is intermediate. This does not turn a nondiagnostic study into 00:11:27.998 --> 00:11:31.816 a negative study. Her symptom occurs during exertion; a resting 00:11:31.944 --> 00:11:34.675 measurement may not reproduce the physiology causing it. 00:11:35.059 --> 00:11:37.875 The next question is which functional assessment can resolve the 00:11:37.918 --> 00:11:43.182 uncertainty and change management. If specialist exercise echocardiography remains inconclusive 00:11:43.310 --> 00:11:47.235 or is not feasible, invasive exercise hemodynamics may be appropriate 00:11:47.320 --> 00:11:49.358 in a center with the required expertise. 00:11:49.689 --> 00:11:52.675 Explain what the additional test will answer, its burdens and 00:11:52.718 --> 00:11:56.208 the alternatives. Do not assume that everyone with obesity needs 00:11:56.293 --> 00:12:00.773 catheterization; persistent symptoms, the probability of disease and the consequences 00:12:00.901 --> 00:12:02.918 of the result drive the decision. 00:12:03.228 --> 00:12:07.879 A 2025 study using selected outpatient diagnostic cohorts found that 00:12:07.921 --> 00:12:10.481 the usual N T pro B N P threshold of 00:12:10.524 --> 00:12:15.004 125 picograms per milliliter had sensitivity of 82 percent when 00:12:15.047 --> 00:12:19.161 body mass index was below 35 and 67 percent when 00:12:19.247 --> 00:12:21.636 body mass index was at least 35. 00:12:22.105 --> 00:12:24.526 This supports caution about a low value in Renee. 00:12:24.814 --> 00:12:27.672 It does not establish a new universal threshold or a 00:12:27.715 --> 00:12:29.720 screening test for asymptomatic people. 00:12:30.062 --> 00:12:34.414 Atrial fibrillation and kidney dysfunction can raise concentrations, while obesity 00:12:34.542 --> 00:12:38.102 can lower them. A single laboratory flag cannot resolve those 00:12:38.188 --> 00:12:42.369 competing influences. Before referral, state one sentence that states the 00:12:42.412 --> 00:12:45.647 clinical uncertainty and one that states the functional loss. 00:12:45.981 --> 00:12:50.290 Then attach the actual echo measurements, rhythm, biomarker value, blood 00:12:50.333 --> 00:12:52.274 pressure history and relevant testing. 00:12:52.552 --> 00:12:55.496 Ask the receiving team to report both the diagnostic conclusion 00:12:55.709 --> 00:12:58.405 and the next treatment or follow-up responsibility. 00:12:58.711 --> 00:13:01.868 A referral succeeds when its answer returns to the clinician 00:13:01.996 --> 00:13:03.785 and patient who need it.